Dearth of mental health treatment options leads to emergencies

Jessica Anderson and Andrea K. Walker, The Baltimore Sun

Bryan Johnson didn't know he had bipolar disorder until he ended up at the emergency room, where he assaulted a police officer.

His family had taken him to the University of Maryland Medical Center because he was acting strangely, staring into the distance and constantly pacing as he struggled with the death of his brother and the loss of his job. He was sent to Central Booking as soon as he was released from the hospital, and wound up with a five-year suspended sentence.

Mental health and law enforcement professionals say patients commonly wind up in emergency rooms and jails that are poorly equipped to handle their disorders, when earlier treatment might have prevented such crises. Even in Maryland, which advocates say is ahead of other states, tight budgets have led to fewer beds in mental health institutions and not enough community programs.

Last month's massacre at a Connecticut elementary school has elevated a long-simmering debate over how to provide care for the mentally ill, as treatment continues to shift from a system of government-run institutions to one that aims to keep people in their communities. Though some who knew the alleged shooter, Adam Lanza, have speculated that he was mentally ill, authorities have not confirmed any diagnosis.

The General Assembly, which opens its 2012 session this week, is also set to consider such issues.

"If you want to have a real talk about multiple killings, we have to address how we make sure these people get the services they need," said Del. Michael Smigiel, an Eastern Shore Republican.

Advocates warn not to generalize about mentally ill people, pointing out that it's uncommon for them to be involved in violent incidents. But there is evidence that those with severe mental disorders such as schizophrenia and bipolar disorder may be slightly more prone to violent acts than the rest of the population.

Violence is one of many problems that become less likely with better treatment, experts say. A recent state report on guns and mental illness said that 5 percent to 7 percent of people with severe problems will harm others in a given year, compared with 2 percent to 3 percent of the general population. Violence becomes more likely when combined with substance abuse, the report said.

The transition from institution- to community-based care has not been smooth, and even supporters say the strategy hasn't worked perfectly. Critics argue that not enough community programs exist, resulting in long waiting lists and people not receiving care. Some people don't know where to get help. Others, like Johnson, don't realize they need it.

Now a mental health counselor, Johnson controls his condition through medication and works to help people deal with problems before they become emergencies like his own.

"We could always use more outreach," Johnson said. "The only question is, are people ready to take advantage of it?"

Mental health issues are likely to come up for debate during the coming General Assembly session, with more pressing consideration given to the issue because of the Connecticut school shootings, which killed 20 schoolchildren and seven adults. Lawmakers are planning bills that would further restrict the ability of people who have been in a mental hospital to own a gun.

A spokeswoman for Gov. Martin O'Malley said he would include mental health initiatives in his legislative package, which will be released in coming weeks. She declined to release details.

A state task force that considered access to guns by the mentally ill released recommendations last week that included seizing firearms from individuals deemed a credible threat to themselves or others. The panel also recommended requiring mental health professionals to report threats, more mental health training for police officers and more education on firearm laws for mental health providers.

"Because of another instance of mass killings by someone with possible mental illness issues … it is inevitable this subject will be legislated before the General Assembly this winter," said Del. Samuel I. "Sandy" Rosenberg, a Baltimore Democrat.

Others want to increase spending on mental health services.

Smigiel, who hopes to introduce legislation to increase psychiatric spending, said the state is moving in the wrong direction with closures of government-run mental health facilities, including one in his district, Upper Shore Mental Health Facility.

Nationally, government-funded mental health programs suffered severe downsizing in recent years even as demand for services increased. States cut nearly $4.4 billion from state mental health budgets from fiscal year 2009 to 2012, according to the National Association of State Mental Health Program Directors Research Institute.

Maryland increased its budget by less than 2 percent in that period, but advocates say it has still cut much-needed programs over the years. Much of the increase came because of increased federal funding.

The state has transitioned from housing people in state institutions to a system relying on community-based programs that allow individuals to live by themselves or with family. Dr. Gayle Jordan-Randolph, a deputy secretary at the state's Department of Health and Mental Hygiene, said the trend encourages recovery.

But Ria P. Rochvarg, an attorney who represents defendants with intellectual disabilities and mental health issues, said the state must provide more community health services if it expects people to count on them.

"They're not choosing to be this way, and they're not choosing to commit crimes," she said. "So how do we fix it?"

Smigiel said the closure of the state facility in his district created a new problem with homelessness because there weren't enough community programs to treat the mentally ill. "They sold us the promise of local community support and services, but people forgot about it."

Many of the untreated end up facing a crisis that lands them in the emergency room or locked up in jail, where workers aren't equipped to handle their needs. Others find that mental problems take over their lives, and they wind up in homeless shelters or living on the streets.

Local jails are trying to figure out how to deal with an increasing number of mentally ill inmates.

"All the detention centers are experiencing that," said Jack Kavanagh, director of the Howard County Department of Corrections. "A quarter of our population has mental health issues."

He added, "Jails are not mental hospitals."

Baltimore County Circuit Judge Nancy M. Purpura said she regularly sees defendants who should be in a mental facility rather than jail. While some defendants who face criminal charges can be released on bail, others must remain in jail until their trial.

"Often what drives their incarceration is the lack of services in the community," Purpura said.

Baltimore County Detention Center Director James P. O'Neill said mentally ill prisoners are waiting three to four weeks to get into Spring Grove Hospital Center to receive treatment.

A report last year by the Justice Policy Institute found that many individuals who were ruled incompetent to stand trial remained in jail even though they weren't convicted, because there were no mental hospital beds available in Maryland.

The most violent mentally ill patients accused of crimes end up at Clifton T. Perkins Hospital Center in Jessup, a maximum-security mental facility. But even there, two people were murdered within a month in 2011, leading to an overhaul of security at the facility, the hiring of a new CEO and other changes.

Conventional hospitals say they aren't equipped to treat mentally ill patients who end up in emergency rooms.

"Many of the people may not be in regular treatment, seeing a regular psychologist or taking the medication that research has found could help them," said Carmela Coyle of the Maryland Hospital Association. "The hospital emergency room becomes the immediate triage center."

State health officials acknowledge the system is not perfect.

"Even though we have good access and good support, there are still people that use emergency rooms and that are homeless. And that just means we have to work harder," said Dr. Brian M. Hepburn, executive director of the Maryland Hygiene Administration, which oversees the state's mental hospitals.

The solution is not increasing the capacity of places like Spring Grove, advocates say. Instead, they call for better ways of linking patients to the right programs and care.

"A person gets out with a referral and it takes weeks and weeks to get an appointment at a clinic" because of shortages of staff or facilities, said Laura Cain, managing attorney with the Maryland Disability Law Center.

Kate Farinholt, executive director of Maryland's chapter of the National Alliance on Mental Illness, said the state needs a greater variety of programs because mental illness affects everybody differently. She also noted that people have to feel comfortable accessing programs because of the stigma associated with mental illness.

She and other mental health advocates said that while the debate following the Connecticut shooting could lead to improvement in mental health care, they warn against broadly blaming mental illness for violent incidents.

"We need mental health treatment available," Cain said. "That's always been the case, but to link it to the shooting is misplaced. It increases stigma."